=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790031276
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEHUL BHALJA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2012
-----------------------------------------------------
Last Update Date | 01/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3311 PRESCOTT RD STE 112
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-542-8856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 846098
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75284-6098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-606-6400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD.208006
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | BP1-0043589
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | MD.208006
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number | MD.208006
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------